HIV/AIDS and the Protection of the Rights of Internally Displaced Persons

Chairperson, Esteemed Members of the UNAIDS Programme Coordinating Board, Distinguished Guests, Ladies and Gentlemen,

I am very grateful to have the honor and privilege to address you today in my capacity as the Representative of the UN Secretary-General on the Human Rights of Internally Displaced persons on this occasion, the twenty-fourth meeting of the UNAIDS Programme Coordinating Board, which is being held on the theme of People on the Move—Forced Displacement and Migrant Populations. I have been asked to discuss the importance of a human rights approach to HIV/AIDS in the context of internal displacement and, in particular, the issue of access of people displaced within their country to essential HIV prevention, treatment, care and support services. In fact, today’s discussion is very timely as such access is often neglected by those providing internally displaced persons (IDPs) with assistance and protection.

Talking about internally displaced persons means talking about large numbers of people all over the world. For many years, the overall number of persons who were forced to flee or to leave their homes in the context of armed conflict has totaled approximately 34-36 million; among them 24-26 million remain as internally displaced persons in their own country. While each year, millions are able to return to their homes or otherwise find durable solutions to their displacement (e.g. by integrating where they have displaced to), displacement continues for others, in new contexts or in the same countries.[1] The same number of people are estimated to be displaced every year by natural disasters, such as earthquakes, wind-storms and flooding. And this number is likely to increase over the next decades as a consequence of climate change. This phenomenon of internal displacement, combined with the estimated 10.5 million refugees worldwide, lead to what UN Secretary General Ban Ki-Moon recently characterized as “arguably the most significant humanitarian challenge we face.”

This challenge is even more serious where it overlaps with other key humanitarian challenges such as the global AIDS epidemic. To which extent this epidemic affects internally displaced persons, however, is unclear. We do not know how many among the internally displaced are suffering from HIV/AIDS.[2] Even less do we know how many IDPs are in danger of being infected with HIV. There is a discussion as to whether HIV/AIDS prevalence is higher among IDPs than among non-displaced communities. The answer seems to be depending on the particular context and available research is largely inconclusive. The Norwegian Refugee Council, summing up research findings in 2006 concluded that: “Data does not support the general perception that IDPs have consistently higher HIV infection rates than the general population nor that conflict necessarily increases the risks of HIV/AIDS infections.” (2006:25). On the other hand, several scenarios can be identified that indicate the high vulnerability of internally displaced persons with regard to HIV/AIDS – scenarios that may not significantly increase the overall percentage of people with HIV/AIDS in a given country but are very serious for the individuals concerned and therefore matter in light of a human rights perspective. In this context, I would like to talk about three particularly relevant issues: (i) Prevention of and protection against HIV transmission in the context of being displaced and during displacement, particularly in camps; (ii) Non-discriminatory access of internally displaced persons to essential HIV prevention, treatment, care and support services with sufficient regard for privacy and confidentiality of their health-related data; and (iii) Non-discriminatory access of internally displaced persons with HIV/AIDS to other essential goods and services, in particular food, water and sanitation, and shelter.

All these topics are not only operational challenges but also directly linked to the human rights of internally displaced persons. Unlike for refugees, there is no international convention outlining their human rights. However, internally displaced persons as citizens or long-term residents of their countries remain entitled to the full protection of human rights and guarantees of international humanitarian law available to the population of the country at large. In addition, the specific rights of IDPs are implicit in international instruments on human rights and international humanitarian law instruments have been explicitly restated in the 1998 UN Guiding Principles on Internal Displacement, a document that, while not binding, draws its authority from the underlining binding guarantees and has been recognized by the 2005 World Summit, the General Assembly and the Human Rights Council as “important international framework for the protection of internally displaced persons.”[3] This document, while not giving IDPs new rights, provides a framework through which to examine the specific needs that IDPs have arising out of their displacement and to assess these needs from a human rights perspective. For instance where access to medical health care systems may be a given in a normal context, for an IDP this may prove to be a challenge because of his or her displacement. A non-displaced person may have documents or been known by his or her usual health care providers, whereas a displaced person may not have the necessary documents to access the health care at his or her place of refuge.

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(i) Prevention of and protection against HIV transmission: Displacement is not just a passing event. It is a devastating transformation of one’s life. It not only means that the displaced lose their homes and livelihoods and are forced to leave behind all they cherished but also that entire social and community networks that foster health and well-being fall apart under the stress of displacement, resulting in marginalization, abject poverty, exploitation, and often sexual and gender-based violence. During situations of displacement, family members are all too often separated from one another. The ensuing break-down of family and community based protection mechanisms increases the risk of sexual violation and abuse. Internally displaced persons, in particular women and girls, but in some settings also men, may become victims of rape. Rape also often occurs in the vicinity of camps, particularly if they are in the vicinity of military installations or hostile communities, and such rape is an important cause of HIV transmission. Recent research[4] indicates that the risk of HIV transmission in the case of an adult woman forced to have sex by unknown combatant assailants is 4.5 times higher than when the woman has the same number of consensual sex acts with one partner from her own community. The risk is 5.3 times higher for women raped by three men in a camp as compared to having three consensual sex acts with a low risk male partner. It is recognized today that rape can be considered as a war crime or a crime against humanity if it is carried out systematically against civilian populations in the context of armed conflict. Human rights obligations of States however may also be triggered in other cases. In particular, States have an obligation to ensure that their armed forces and its members refrain from acts of rape. To the extent possible, they must also provide protection against rapes by non-state actors, e.g. by providing firewood patrols in the vicinity of IDP camps. In all cases, States have a human rights obligation to investigate cases of rape and to prosecute and punish perpetrators. As experience shows, widespread impunity is a particularly important source of sexual violence, and as mentioned such violence may transmit HIV. While rape does not translate into an overall population increase in HIV prevalence and thus, in a public health perspective, is of limited relevance for the situation in a given country, it creates individual risks that are highly relevant from a human rights perspective.

Higher risks of infection also exist where sex is exchanged for food and other goods and services or favors with humanitarian workers and peacekeepers. It is estimated that even in this setting the risk of HIV transmission is 1.5 higher for a woman than the risk of attracting HIV in the context of consensual sex with a man from her own community.[5] A human rights perspective requires that aid agencies and States providing peacekeepers must introduce and implement zero-tolerance policies regarding such practices and investigate all reported cases as well sanction perpetrators.

The risk of transmission also exists when IDPs remain without livelihood opportunities, be it in the context of protracted displacement or in return areas where the economy remains destroyed, forcing displaced women to engage in sex work to survive. I still remember the young mother of three in an urban return area without any employment opportunities telling us when asked about HIV that she knew everything about the risks of transmission and adding: “However, when the man offers you three times the money if you do it without condom and your children are crying hungry at home, you do not think.” In such cases, early recovery programs addressing transitional humanitarian assistance and restoration of livelihoods should specifically target women at risk of becoming sex workers for reasons of poverty.

Finally, I have seen in my work that one of the consequences of displacement, be it in armed conflict or due to a natural disaster, is an increase in domestic violence and abuse. Here again, particularly in social contexts where men have multiple partners, women are at a higher risk of being abused and also of being forced to have unprotected sex, thus putting them at further risk of becoming infected.

(ii) Non-discriminatory access to essential HIV prevention, treatment, care and support services with sufficient regard for privacy and confidentiality of their health-related data: Whether they may be living in camps, among host families, or elsewhere, internally displaced persons may also find themselves without access to adequate medical care, including HIV/AIDS treatment as a result of their displacement. The situation can be particularly acute in conflict and post-conflict environments, as well as following natural disasters, where these facilities and services have been physically destroyed along with other social infrastructures and where health care workers have themselves been forced to flee resulting in the availability of only limited resources at best to care for the displaced as well as the population at large. Particularly problematic are situations where displacement interrupts antiretroviral therapies, and where antiretroviral drugs are not available in camps or other locations patients have been displaced to – either because they are not stocked in such areas or because such therapies are not considered as life-saving measures that should be offered to internally displaced persons. It is also not uncommon for IDPs, many of whom are displaced to remote areas, to suffer from a lack of access to those medical care facilities and services that do exist. In these situations, displaced persons with HIV/AIDS may be physically unable to travel or may be prevented from reaching population centers where medical facilities and medicines are located on account of curfews, checkpoints, or threats to their safety such as exposure to mines and unexploded ordinances. Finally, in many situations, condoms are not easily accessible to IDPs, meaning that sex – whether consensual or not – is unprotected, thus furthering the risk of HIV infection.

Where medical facilities and services are within physical reach to the displaced, IDPs with HIV/AIDs may still lack access to care and medicines on account of a number of obstacles. In some countries, raped women among the IDPs can only access medical treatment and receive the necessary treatment to reduce the risk of infections if they had gone to the police to report the case first – something many women fear to do for valid reasons. For those on antiretroviral drugs or other HIV/AIDS related treatment, obstacles can range from decisions to deny or delay access to treatment because of concerns about the burden they will place on what may be a resource poor medical infrastructure and its ability to respond to the needs of the non-displaced community to linguistic, financial, and bureaucratic obstacles. In some instances, IDPs are unable to seek or obtain HIV/AIDS treatment because they do not speak the local language. IDPs may also suffer discrimination on the basis of their ethnicity or other attributes and therefore be denied treatment. In addition, IDPs frequently lack financial resources to pay for HIV/AIDS related medical care and often do not have access to documentation that establishes their identities for purposes of seeking and receiving treatment. Similarly, IDPs will most likely not be able to produce medical records and other documentation that could provide health workers with necessary information about pre-existing conditions and courses of treatment.

It is also important to note that in some circumstances where IDPs have access to medical facilities, the services and treatment provided may not be respectful or sensitive to culture, ethnicity, gender, age, or individualized preferences of the displaced. Services that ignore issues related to gender based violence or dietary restrictions for instance are not uncommon and can present an additional obstacle to IDPs with HIV/AIDS.

All these obstacles may amount to a violation of the right to health. The right to health, as embodied in general in many human rights conventions[6] and more specifically restated in the Guiding Principles on Internal Displacement[7] requires that relevant medical goods and services

(1) are made available to IDPs in sufficient quantity and quality;

(2) are physically, economically and administratively accessible, i.e. within safe physical reach for internally displaced persons; free or economically affordable even for those among the displaced who have no or only very limited sources of income; and free or administrative obstacles such as documentation requirements (e.g. possession of ID cards or birth certificates) that IDPs cannot necessarily meet because their personal documents were left behind when they had to leave or flee or were lost or destroyed during flight. Of course, the availability of relevant goods and services must be made known to internally displaced persons;

(3) are acceptable, i.e. respect medical ethics as well as the cultural, gender, and life cycle requirements of individuals or groups. Respect for the privacy of HIV/AIDS patients and confidentiality of their health related data is particularly important to make services acceptable for persons fearing stigmatization based on their health status;

(4) are non-discriminatory, i.e. provided on the basis of need and without discrimination based on the gender, age, ethnic origin, religion, social status or political opinion of the displaced persons concerned.

Each of these elements can also be thought of as components of the goal of Universal Access. To realize this goal, it is necessary to include HIV/AIDS related measures and activities into humanitarian assistance programs, to identify, in a particular situation, those with HIV/AIDS among the internally displaced[8] and to assess their specific needs, in order to plan, on the basis of such assessment, necessary measures and interventions. To facilitate this, internally displaced persons should be integrated into the countries’ National Strategic Plans (NSP) for HIV/AIDS.

(iii) Non-discriminatory access of internally displaced persons with HIV/AIDS to other essential goods and services, in particular food, water and sanitation, and shelter: Such access may meet obstacles or become even impossible because persons with HIV/AIDS are, e.g., to weak to stand in line during hours when food is distributed, or discriminated against and marginalized by other IDPs when their health conditions becomes known. Again, it is necessary for humanitarian actors and States to identify such problems and to take the necessary operational, administrative and legal measures necessary to ensure that HIV/AIDS does not become the reasons why such persons are excluded from the enjoyment of their subsistence rights as guaranteed by relevant international human rights instruments.

Finally, there is the important point of discrimination against IDPs with HIV/AIDs. In many countries, these persons are doubly shunned: from the outside community because they are IDPs and even from within their community because they have HIV/AIDS. In situations where this is not carefully monitored, they are the last to get food, they have the worst living conditions, and receive little assistance from other IDPs to manage their daily lives. If you consider the growing rate of single-headed households in an IDP setting, of which many are children, some of which are HIV infected, then you can imagine the extent of misery these people face.

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Ladies and Gentlemen, let me conclude. The challenges to meeting the protection and assistance needs of people on the move, including IDPs, and ensuring their human rights, such as the right to health through universal access to HIV protection programs and to treatment, care, and support, are significant. A human rights based approach to internal displacement, however, helps to determine what must be done to protect displaced persons against HIV transmission and ensure that those with HIV/AIDS among the displaced receive treatment in accordance with their specific needs and vulnerabilities.

I am very encouraged by the commitment shown by UNAIDS and other actors at the international and domestic levels to better understand the complexities of displacement and to address the health, well being, and the HIV-related needs of internally displaced persons along with other “people on the move” that arise in humanitarian situations. I remain at your disposal to support you in these efforts.

Thank you.

[1] According to the most recent global report of the Internal Displacement Monitoring Center (IDMC), more than 26 million people—located in more than 50 countries—were internally displaced in 2008 on account of armed conflict, situations of generalized violence, or human rights violations. Africa was the region most affected by internal displacement, with 11.6 million IDPs found in 19 countries in 2008. In addition, this past year there were an estimated 4.5 million conflict-induced IDPs in the Americas, 3.9 million IDPs in the Middle East, 3.5 million IDPs in South and South-east Asia, and an additional 2.5 million IDPs in Europe and Central Asia. Also in 2008, the largest IDP populations were found in Sudan (4.9 million), Colombia (2.6 – 4.3 million), and Iraq (2.8 million). In 2009, we have seen the numbers of internally displaced persons around the world grow with an increase of roughly 3 million IDPs in Pakistan and more than one hundred thousand new IDPs in Sri Lanka as a result of the conflicts in both countries.

[2] A 2006 review of information on eight countries with large IDP populations found that data on HIV prevalence among IDPs existed only for limited situations in Sudan and DRC. Paul Spiegel and Hélène Harroff-Tavel, HIV/AIDS and Internally Displaced Persons in 8 Priority Countries (Geneva: UNHCR, January 2006), 18.

[3] Summit Outcome Document, General Assembly resolution 60/1, para. 132; General Assembly resolution 62/153, para. 10; Human Rights Council resolution 6/32, para. 5.

[4] London International Development Center, HIV/AIDS, Rape and Conflict: Predictions Based on Mathematical Modelling, 04 January 2009at: http://www.lidc.org.uk/news_detail.php?news_id=45 (visited on 21 June 2009).

[5] Id.

[6] The right to health and access to medical services for IDPs is based on various provisions of international law, including Article 25(1) of the Universal Declaration of Human Rights, which sets forth the right to medical care, and also Article 12 of the International Convention on Economic, Social, and Cultural Rights, which affirms this right in greater detail. Other legally binding provisions that affirm the nature and scope of right to health can be found in the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), and the Convention on the Rights of the Child (CRC). In addition, the right to health has been given greater specificity by General Comment 14 of the United Nations Committee on Economic, Social, and Cultural Rights and the work of the Special Rapporteur on the Right to Health.

[7] In matters related to the health of IDPs, Guiding Principles 18 and 19 articulate the rights and obligations aimed at ensuring that IDPs have access to essential medial services and that special attention be given to the health needs of women and to prevention of diseases such as HIV/AIDs. For instance:[7]

• According to Guiding Principle 18(2)(d), “[a]t the minimum, regardless of the circumstances and without discrimination, competent authorities shall provide internally displaced persons with and ensure safe access to: … [e]ssential medical services.
• In addition, Guiding Principle 19(1) provides, “[a]ll wounded and sick internally displaced persons as well as those with disabilities shall receive to the fullest extent practicable and with the least possible delay, the medical care and attention they require, without distinction on any grounds other than medical ones.”
• Paragraph 19(2) goes on to state “[s]pecial attention should be paid to the health needs of women, including access to female health care providers…, as well as appropriate counseling for victims of sexual and other abuses.”
• Notably, paragraph 19(3) establishes that special attention be given to the “prevention of infectious diseases, including AIDS, among internally displaced persons.”

In addition, Principle 29 recognizes the right of IDPs to access public services such as medical treatment without discrimination once they have found a durable solution to their displacement by returning home or settling in another part of the country. Similarly, Guiding Principle 1 affirms the right of IDPs to equality and freedom from discrimination at all times.

[8] See UNHCR/UNAIDS, HIV-related Needs in Internally Displaced Persons and Other Conflict-affected Populations: A Rapid Situation Assessment Tool, Geneva 2007.